Erection loss with condoms predicts subsequent unsafe sex

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If gay men experience erection loss when they use condoms for insertive anal sex, they are both less likely to use condoms over the following six months, and less likely to intend to use condoms, Dutch researchers have found. So called COINED - COndom INduced Erectile Dysfunction – was such a strong independent predictor of subsequent premeditated, as opposed to unpremeditated, unprotected sex, the researchers found, that it could be used as a ‘surrogate marker’ for it.

Furthermore because erection loss influenced future sexual behaviour, traditional motivation-based prevention strategies that increase risk perceptions or motivation to use condoms in the present might not work, the researchers conclude.

The Dutch researchers looked at the relationship between COINED and deliberately risky sexual behaviour in 435 men, 6% of them HIV-positive, taking part in the Amsterdam Cohort Studies of Homosexual Men.



Insertive anal intercourse refers to the act of penetration during anal intercourse. The insertive partner is the ‘top’. 

odds ratio (OR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

surrogate marker

An indirect indicator of something, such as measuring viral load to assess the treatment effect of a drug.



A serodiscordant couple is one in which one partner has HIV and the other has not. Many people dislike this word as it implies disagreement or conflict. Alternative terms include mixed status, magnetic or serodifferent.

unprotected anal intercourse (UAI)

In relation to sex, a term previously used to describe sex without condoms. However, we now know that protection from HIV can be achieved by taking PrEP or the HIV-positive partner having an undetectable viral load, without condoms being required. The term has fallen out of favour due to its ambiguity.

COINED was self-defined as ‘prematurely losing erection when using condoms’ and was measured with a five point scale (1= never to 5= always), and was corrected for other types of erectile dysfunctions.

The men, mean age 34 years, were asked to complete questionnaires detailing self-reported COINED, deliberate and non-deliberate risky unprotected insertive anal intercourse (UIAI) with casual and steady partners, and their intentions to use condoms.

Deliberate risk was defined as UIAI that was planned in advance, while COINED was defined as loss of erection because of condom use.

The data from the questionnaires suggested rates of UIAI reached 18% (55/306) with casual partners and 17% (46/272) with steady partners of discordant or unknown HIV status.

Ten per cent frequently experienced COINED with casual partners and 7% with steady partners.

Further analysis suggested that COINED was not associated with UIAI with steady partners. But among casual partners, COINED was significantly associated with deliberate UIAI (odds ratio of 6.57) but not with non-deliberate UIAI.

The researchers conclude that COINED is a unique predictor of deliberate UAI between casual partners.

If men experienced COINED they were 2.71 times more likely, six months later, to have risky UIAI (p =

Since COINED influences the intention to use condoms in advance, traditional, intention-based prevention strategies will probably be ineffective in addressing this problem and alternative strategies, “such as the prescription of erectile medication like Viagra,” should be sought, comment the researchers.

Questioned about the fact that Viagra use is in itself a strong independent predictor of unsafe sex, presenter Udi Davidovich commented that “men who use Viagra to achieve five or six orgasms a night” might not be the same as men who need it simply to be “tops”, though careful questioning would be needed to distinguish this.

Asked if he had asked whether the erection loss was also, or independently, associated with recreational drug use, he said that this had not been analysed for the purposes of this study but could be done as the data on drug use was there. However he felt that the survey questions were designed to make it clear that the researchers were looking specifically for erection loss following condom use.

A German audience member commented that in a similar survey he had investigated the link between antiretroviral drugs and erectile dysfunction in HIV-positive patients and had found a negative correlation – in other words, erectile dysfunction was more common in patents not taking antiretrovirals, indicating a possible psychological cause.